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Radiation Safety

Time- limit amount of exposure Distance - don't stand close to pt shielding- use lead shields during procedures

Independant nursing Actions

dont require a Dr's order. Ex. removing a blanket for a pt with fever

Dependant nursing Actions

Dr's order required. Ex. giving meds, IV flushes

Collaborative Nursing Action

Involves several aspects of nursing. Ex. pt discharged to a nursing home with oxygen and a walker.- involves Dr, PT, Resp, Social worker.

evidence based practice

using findings from research, quality improvement and pt assessments in combination with clinical expertise and pt preferences, values in clinical decision making

SOAPIE

S-subjective O-objective A-assessments P-plan I-implementation E- evaluation

SOAPIE is used with ____

POMR's (problem oriented medical records)

ADPIE

A-assessment D-diagnosis(nursing) P-planning I-implementation/ intervention E-Evaluation

Initial assessment

When you first meet the patient. ABC's and neuro checks

Focused Assessment ( secondary)

change of shift, do a quick assessment while getting report

nursing Diagnosis

must be measurable, ex. seen, heard, felt or measured by another person.

SOLER ( for communicating with patients)

S-Sit quietly facing pt O-open posture (no crossed arms) L-Lean forward toward them E- eye contact R- relax

Chx: of pain (acute)

mild to severe , affects SNS, increased pulses, increased respirations, increased BP, restlessness, anxiousness, diaphoretic, py reports pain, crying, splinting, rubbing area

Chx: of pain (chronic)

mild to severe, affects PNS, v/s normal, skin is dry, pt depressed, withdrawn, doesnt mention pain unless asked, abscence of pain behaviors

Nociceptive Pain

due to damage of normal tissue or has the potential to do so.

Somatic Pain

comes from bones, joints, muscles, skin or connective tissue

visceral Pain

Pain in abdomen, cranium, thorax

Pain Threshold

least amount of pain stimulation a person requires in order to feel pain

Pain Tolerance

How much pain the pt can take

PQRST (Pain)

P-pain location Q-quality of pain R-radiates? S-severity of pain T-time/duration of pain

Primary Care

health promotion, immunizations, early detection and treatment

Secondary care

emergency care, diagnosis and treatment, acute care

Tertiary care

long term care, care of the dying, rehab

Physical Assessmet

IPPA inspect, palpate, percuss, auscultate. except abdomen- IAPP inspect, aucultate, percuss, palpate

Subjective data

pt says " i have pain"

Objective data

what you see, discoloration of skin, increased lab values

3 stages of Selyes Adaption

Alarm, resistance, Exhaustion

Alarm stage of Selye

alerts the body's defenses

Resistance stage of Selye

body's adaption takes place, body attempts to cope with stress

Exhaustion stage of Selye

body can no longer remain in resistance. either goes back to normal and relaxes or death occurs

Homeostasis

tendency of body to maintain a state of balance or equilibrium, while continually changing

Adaption

body changes to stay in homeostasis, to achieve a balance between demands and resources

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